Cross-sectional studies indicate that uninsured adults in the United
States receive less appropriate care and have worse health outcomes than insured
adults, but these studies are limited by unmeasured factors associated with
insurance status. In this longitudinal study of adults before and after they
became eligible for Medicare at age 65 years, McWilliams and
colleaguesArticle found that differences in the use of cholesterol testing,
mammography, and prostate examination between those who were continuously
insured prior to Medicare eligibility and those who were continously uninsured
were significantly reduced after Medicare eligibility. Among adults with arthritis
or hypertension, however, differences in use of disease-specific medications
between continuously uninsured and insured adults did not significantly diminish
after Medicare eligibility. In an editorial, Bindman and HaggstromArticle
suggest that major reform rather than incremental change is necessary to address
the problem of uninsured Americans.

Guggulipid for Treatment of Hypercholesterolemia

Guggul, an extract from the resin of the mukul myrrh tree, is widely
used in Asia to reduce cholesterol levels and is increasingly being used in
the United States, where it is available as a dietary supplement. In this
randomized trial among healthy adults with hypercholesterolemia eating a typical
Western diet, Szapary and colleagues found that standardized guggul extract
(guggulipid, containing 2.5% guggulsterones) was not effective in lowering
cholesterol levels after 8 weeks of therapy. Low-density lipoprotein cholesterol
levels increased 4% in the standard-dose guggulipid group and 5% in the high-dose
guggulipid group, whereas they decreased 5% in the placebo group.

Predictors of Early Readmission After CABG Surgery

Early readmission following coronary artery bypass graft (CABG) surgery
is an important adverse outcome of CABG surgery and may be a useful measure
for quality assessment. Hannan and colleagues analyzed data from patients
who underwent CABG surgery in New York State in 1999 and found that almost
13% of patients were readmitted within 30 days for reasons related to CABG
surgery. Higher early readmission rates were associated with patient-level
risk factors, including female sex, older age, and African American race,
provider characteristics, and postoperative factors.

Addition of HPV Vaccine to Screening for Cervical Cancer

Vaccines for prevention of cervical infection with human papillomavirus
(HPV) types that are associated with a high risk of cervical cancer may become
available within the next 5 to 10 years. Kulasingam and Myers used mathematical
modeling to identify potentially cost-effective strategies for adding vaccination
to existing conventional cytology-based screening programs. Vaccination allowed
the onset of screening to be delayed. Vaccination at age 12 years plus biennial
screening delayed until age 24 years had the most attractive cost-effectiveness
ratio. The cost-effectiveness of vaccination plus delayed screening depended
on maintaining vaccine efficacy during the ages of peak incidence of oncogenic
HPV infection.

Variations in End-of-Life Care in European ICUs

Sprung and colleaguesArticle conducted a prospective,
observational cohort study to examine end-of-life practices in 37 intensive
care units (ICUs) in 17 European countries. From January 1, 1999, to June
30, 2000, 9.8% of patients admitted to ICUs had limitations of life-sustaining
therapy. The limitations and manner of dying varied substantially between
countries. Limitation of therapy was associated with patient age, acute and
chronic diagnoses, number of days in ICU, region, and physician religion.
In an editorial, Rocker and CurtisArticle discuss factors that
may contribute to geographic variation in end-of-life care.

A program that allows physicians to offer in-office treatment to opiate-addicted
patients has been hailed as a way to "de-ghettoize" treating such individuals.
But few physicians have embraced the opportunity.

National Health Insurance

A proposal for a single-payer national health insurance program with
universal, comprehensive coverage that would both expand access to care and
reduce costs.

Clinician's corner

Excerpts of interviews with a 33-year-old man with advanced HIV infection,
his aunt, and his physician illustrate the importance of a comprehensive treatment
plan that integrates curative or disease-specific interventions and symptom
palliation.